A review of studies concerning treatment adherence of patients with anxiety disorders

Lívia Santana1, Leonardo F Fontenelle1–31Anxiety and Depression Research Program, Institute of Psychiatry, Universidade Federal do Rio de Janeiro, Brazil; 2Department of Psychiatry and Mental Health, Institute of Community Health, Universidade Federal Fluminense, Brazil; 3D’Or Institute for Research and Education (IDOR), Rio de Janeiro, BrazilObjective: This paper aimed at describing the most consistent correlates and/or predictors of nonadherence to treatment of patients with different anxiety disorders.Method: The authors retrieved studies indexed in PubMed/MedLine, PsycINFO, and ISI Web of Knowledge using the following search terms: attrition OR dropout OR attrition rates OR patient dropouts OR treatment adherence AND anxiety disorders. Research was limited to articles published before January 2010.Results: Sixteen studies were selected that investigated the impact of sociodemographic, clinical, or cognitive variables on adherence to treatment for anxiety disorders. While no consistent pattern of sociodemographic or clinical features associated with nonadherence emerged, all studies that investigated cognitive variables in panic disorder, social anxiety disorder, and obsessive-compulsive disorder found that expectations and opinions about treatment were related to adherence.Conclusion: The findings of this study suggest that it is essential to consider anxiety disorder patients’ beliefs about illness and treatment strategies to increase their compliance with the therapeutic plan.Keywords: attrition, dropout, OCD, obsessive-compulsive disorder, social anxiety disorde

The Neuroprotective Disease-Modifying Potential of Psychotropics in Parkinson's Disease

Neuroprotective treatments in Parkinson's disease (PD) have remained elusive. Psychotropics are commonly prescribed in PD without regard to their pathobiological effects. The authors investigated the effects of psychotropics on pathobiological proteins, proteasomal activity, mitochondrial functions, apoptosis, neuroinflammation, trophic factors, stem cells, and neurogenesis. Only findings replicated in at least 2 studies were considered for these actions. Additionally, PD-related gene transcription, animal model, and human neuroprotective clinical trial data were reviewed. Results indicate that, from a PD pathobiology perspective, the safest drugs (i.e., drugs least likely to promote cellular neurodegenerative mechanisms balanced against their likelihood of promoting neuroprotective mechanisms) include pramipexole, valproate, lithium, desipramine, escitalopram, and dextromethorphan. Fluoxetine favorably affects transcription of multiple genes (e.g., MAPT, GBA, CCDC62, HIP1R), although it and desipramine reduced MPTP mouse survival. Haloperidol is best avoided. The most promising neuroprotective investigative priorities will involve disease-modifying trials of the safest agents alone or in combination to capture salutary effects on H3 histone deacetylase, gene transcription, glycogen synthase kinase-3, α-synuclein, reactive oxygen species (ROS), reactive nitrogen species (RNS), apoptosis, inflammation, and trophic factors including GDNF and BDNF

Investigating the role of anticipatory reward and habit strength in obsessive-compulsive disorder

Aims: To determine the rates and associated illness characteristics of obsessive-compulsive disorder (OCD) patients who describe their symptoms as either rewarding or habitual. Methods: Seventy-three treatment-seeking OCD patients had their dominant compulsive behavior assessed with a structured interview (the Temporal Impulsive-Compulsive Scale–Revised) to track the progression of rewarding (ie, gain in positive affect), aversive (ie, decrease in negative affect), and neutral (or non-affective) states and a self-report scale (the Self-Report Habit Index) to evaluate their habitual features. Additional measures included structured diagnostic interviews for axis I and II disorders, measures of OCD symptoms severity, and a battery of instruments to comprehensively assess relevant aspects of sensitivity to reward and fear. Results: Almost half (49%) of our OCD patients (particularly washers) endorsed that they anticipated obtaining a reward (ie, positive affect) from the enactment of their dominant compulsive behavior. Washers stood out in that their positive affects during and after compulsive behaviors were highly (and positively) correlated with duration of illness. In contrast, habit strength did not differ between washers, checkers, and arrangers, although it also correlated with duration of illness among checkers. Furthermore, the severity of OCD and comorbidity with impulse control disorders predicted up to 35% of the variance in the habit strength of OCD behaviors. Conclusion: Compulsive washing may be more clearly characterized by problems in reward processing. In contrast, duration of checking, severity of OCD, and comorbidity with impulse control disorders shape compulsive behaviors by imparting them with habitual tendencies

A construção de um novo instrumento para avaliar correlatos implícitos dos sintomas do transtorno obsessivo-compulsivo: primeira versão do Teste de Associação Implícita

BACKGROUND: The lack of an implicit measure for the obsessive-compulsive disorder symptoms limits its assessment to the traditional scales and inventories. OBJECTIVES: The aim is the construction of an instrument for the evaluation of obsessive-compulsive symptoms that is independent from examinee's self-evaluation [i.e. the Implicit Association Test for obsessive-compulsive disorder (IAT-OCD)]. METHODS: In order to build the IAT-OCD, we consulted (1) previous studies that employed the IAT for the evaluation of other psychiatric symptoms; (2) expert psychiatrists and psychologists with experience in the assessment and treatment of patients with OCD; and (3) patients with OCD themselves. RESULTS: Specific verbal and visual stimuli were selected for each obsessive-compulsive symptom dimensions (contamination-washing, obsessions-checking, symmetry and hoarding). A software designed to measure reaction time in miliseconds (a proxy for implicit association) was developed. A final version of the IAT-OCD was then obtained. DISCUSSION: The IAT-OCD expands the existing armamentarium to evaluate obsessive-compulsive symptoms, especially among those individuals who report badly about their symptoms.CONTEXTO: A inexistência de uma medida implícita para sintomas do transtorno obsessivo-compulsivo (TOC) limita a avaliação às escalas e aos inventários tradicionais. OBJETIVOS: O objetivo foi construir um instrumento de avaliação de sintomas obsessivo-compulsivos que independa da autoavaliação pelo examinando [por exemplo, o Teste de Associação Implícita para transtorno obsessivo-compulsivo (TAI-TOC)]. MÉTODOS: A fim de construir o TAI-TOC, foram consultados (1) estudos anteriores que utilizaram o TAI para avaliação de outros sintomas psiquiátricos, (2) psiquiatras e psicólogos com experiência na avaliação e tratamento de pacientes com TOC e (3) os próprios pacientes com TOC. RESULTADOS: Estímulos verbais e visuais foram selecionados para cada dimensão dos sintomas obsessivo-compulsivos (contaminação e lavagem, obsessões de checagem, simetria e colecionismo). Um software projetado para mensurar o tempo de reação em milissegundos (um programa para associação implícita) foi desenvolvido. Uma versão final do TAI-TOC foi obtida. CONCLUSÕES: O TAI-TOC expande o arsenal existente para avaliação dos sintomas obsessivo-compulsivos, especialmente naqueles indivíduos que informam mal sobre seus sintomas

O Teste de Associação Implícita no transtorno obsessivo-compulsivo (TAI-TOC): consistência interna e correlações com medidas explícitas

BACKGROUND: Traditional assessments of obsessive-compulsive symptoms, based on patients' introspection, are subject to several factors, including the levels of insight presented by them. OBJECTIVES: In this study, our goal was to assess the internal consistency and clinical correlations of a test that seeks to identify the existence of an implicit cognitive bias in patients with obsessive-compulsive disorder (OCD). METHODS: 40 patients with OCD performed the implicit association test for OCD (IAT-OCD) and answered three instruments of self-assessment [Beck Anxiety Inventory (BAI), Inventory, Beck Depression Inventory (BDI), Obsessive-Compulsive Inventory-Revised (OCI-R)]. RESULTS: Cronbach's alpha with IAT-OCD training items was 0.83 and without them 0.79. There were no significant correlations between the IAT-OCD scores and the instruments of self-assessment, e.g., BDI, BAI and different dimensions of the OCI-R. DISCUSSION: Our findings are consistent with a high internal consistency of the IAT-OCD. The absence of correlations between the IAT-OCD and different dimensions of the OCI-R suggests that implicit and explicit measures of obsessive-compulsive symptoms may be independent constructs. Future studies, with greater number of patients, are needed to confirm this hypothesis.CONTEXTO: Avaliações tradicionais de sintomas obsessivo-compulsivos, baseadas na introspecção, estão sujeitas a diversas variáveis, como os níveis de insight apresentados pelo paciente. OBJETIVOS: Neste estudo, nosso objetivo foi o de avaliar a consistência interna e as correlações clínicas de um teste que busca identificar a existência de um viés cognitivo implícito em pacientes com transtorno obsessivo-compulsivo (TOC). MÉTODOS: Quarenta pacientes com TOC realizaram o teste de associação implícita para o TOC (TAI-TOC) e responderam a três instrumentos de autoavaliação [Inventário de Ansiedade de Beck (BAI), Inventário de Depressão de Beck (BDI), Inventário de Obsessões e Compulsões - Revisado (OCI-R)]. RESULTADOS: O valor do alfa de Cronbach com itens de treino foi de 0,83 e sem o treino foi de 0,79. Não foram observadas correlações significativas entre os escores gerados pelo TAI-TOC e os instrumentos de autoavaliação, i.e., BDI, BAI e diferentes dimensões do OCI-R. CONCLUSÃO: Nossos achados apontam para uma elevada consistência interna do TAI-TOC. A ausência de correlações entre o TAI-TOC e diferentes dimensões do OCI-R sugere que medidas implícitas e explícitas de sintomas obsessivo-compulsivos podem formar constructos independentes. Estudos futuros, com maior número de pacientes, são necessários para confirmar essa hipótese

Toxina botulínica como tratamento para fobia social generalizada com hiperidrose

BACKGROUND: Blushing, trembling, and sweating are frequently seen in social phobia. OBJECTIVES: In this study, we aimed at describing the response of a patient with a generalized type of social phobia and hyperhydrosis to cognitive-behavioral therapy augmented by botulinum toxin. METHOD: Single case report. RESULTS: Mr. A, a 20 year-old university student, sought treatment in our unit for social phobia with comorbid depression. Mr. A also exhibited a diagnosis of palmar, plantar, and axilar hyperidrosis. He described that exposure to feared situations always lead to aggravation of sweating and other symptoms of heightened physiological arousal. Both social phobia and hyperhydrosis had their onset in early adolescence, with the former beginning four years before the latter. Cognitive-behavioral therapy led to aliviation of depression but effective treatment of social phobia was only possible after therapy with botulinum toxin. DISCUSSION: Botulinum toxin, a treatment that blocks peripheral autonomic symptoms, might also lead to improvement of social phobia.CONTEXTO: Enrubescimento, tremores e transpiração excessiva são fenômenos frequentemente observados na fobia social. OBJETIVOS: Descrever a resposta de um paciente com o tipo generalizado de fobia social e hiperidrose à terapia cognitivo-comportamental aliada à toxina botulínica. MÉTODO: Relato de caso único. RESULTADOS: O Sr. A, 20 anos, estudante universitário, procurou tratamento por apresentar sintomas compatíveis com os diagnósticos de fobia social e depressão. O Sr. A também apresentava diagnóstico de hiperidrose palmar, plantar e axilar. Tanto a fobia social quanto a hiperidrose tiveram seu início no começo da adolescência, com a primeira se iniciando quatro anos antes da segunda. A terapia cognitivo-comportamental levou à remissão da depressão, mas o tratamento efetivo da fobia social apenas foi possível após a terapia com a toxina botulínica. CONCLUSÃO: A toxina botulínica, um tratamento que bloqueia fenômenos autonômicos periféricos, também pode proporcionar alívio dos sintomas em pacientes com fobia social